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Download Travel Questionnaire - Manor Street Surgery
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Once completed, please hand to a member of reception and make a telephone appointment in the Travel Advice Clinic. Travel Questionnaire Personal Details Name: Sex: Date of Birth: Postcode: Female Male Daytime Tel: Email: Third party consent: I give consent for ___________________________________ to discuss my medical information regarding my travel requirements. Signed: Name: Trip Dates Departure: Duration: Itinerary Country Duration Availability of Medical Help (i) Trip Description - please tick all appropriate boxes: Purpose of Trip: Type of Trip: Accommodation: Travelling: Location Type: Activity Type: Business Pleasure Other Package Self-Organised Backpacking Camping Cruise Ship Trekking Hotel Friends/Family Other Alone With Friend/Family In a Group Urban Rural Altitude(i) Safari Adventure Other Once completed, please hand to a member of reception and make a telephone appointment in the Travel Advice Clinic. Personal Medical History List all chronic medical conditions that you have (eg. diabetes, heart or lung conditions) List all allergies that you have (eg. eggs, nuts, antibiotics) If you have had a serious reaction to a vaccine in the past, which vaccine was it? List all of your current medications (including oral contraception) Have you recently suffered from any infection (e.g heavy cold, flu or high temperature)? Does having an injection cause you to feel faint? Do you or any close family members have epilepsy? Yes Yes Yes Do you have any history of mental illness including depression or anxiety? Yes Have you recently undergone radiotherapy, chemotherapy or steroid treatment? Yes Have you taken out travel insurance? Yes If you have a medical condition, have you told your insurance company about it? Are you pregnant, planning pregnancy or breast feeding? Yes Yes Write below any further information that might be relevant Vaccination History Have you ever had any of the following vaccinations / tablets and if so, when? Tetanus Diphtheria Hepatitis A Meningitis Influenza Yes Yes Yes Yes Yes Polio Typhoid Hepatitis B Yellow Fever Rabies Yes Yes Yes Yes Yes Once completed, please hand to a member of reception and make a telephone appointment in the Travel Advice Clinic. Jap B Enceph Malaria Tablets Tick Borne Yes Yes Other Yes For Official Use Travel Risk Assessment Performed Disease Protection Yes Performed Hepatitis A Yes No Hepatitis B Yes No Typhoid Yes No Cholera Yes No Tetanus Yes No Diptheria Yes No Polio Yes No Meningitis ACWY Yes No Yellow Fever Yes No Rabies Yes No Jap B Enceph Yes No Other Yes No Further Information Travel Advice and Leaflets Given Food, water & personal hygiene advice Travellers’ diarrhoea Hepatitis B and HIV Insect Bite Prevention Animal Bites Accidents Insurance Air Travel Once completed, please hand to a member of reception and make a telephone appointment in the Travel Advice Clinic. Sun and Heat Protection Websites Travel Record Card Supplied Other Malaria Prevention Advice and Chemoprophylaxis Chloroquine & Proguanil Atovaquone & Proguanil (Malarone) Chloroquine Mefloquine Doxycycline Malaria Advice Leaflet Given Signed:-………………………………………………………… Position:…………………………………… Date:………………….. Signed:-………………………………………………………… Position:…………………………………… Date:…………………….
